Provider Demographics
NPI:1972073849
Name:MICHAEL W HUBBERT DMD, LLC
Entity type:Organization
Organization Name:MICHAEL W HUBBERT DMD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:HUBBERT
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:601-776-3370
Mailing Address - Street 1:99 HIGHWAY 511
Mailing Address - Street 2:
Mailing Address - City:QUITMAN
Mailing Address - State:MS
Mailing Address - Zip Code:39355-8899
Mailing Address - Country:US
Mailing Address - Phone:601-776-3370
Mailing Address - Fax:601-776-3373
Practice Address - Street 1:99 HIGHWAY 511
Practice Address - Street 2:
Practice Address - City:QUITMAN
Practice Address - State:MS
Practice Address - Zip Code:39355-8899
Practice Address - Country:US
Practice Address - Phone:601-776-3370
Practice Address - Fax:601-776-3373
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-04
Last Update Date:2018-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00060139Medicaid